29yrs old Primi at 24 weeks of pregnancy was brought to the emergency by ambulance in shock with complaints of sudden onset of epigastric pain and dizziness. There was no complaint of bleeding per vaginum.
The patient was resuscitated and urgent ultrasound was done which revealed massive hemoperitoneum with intra uterine fetal death. Emergency laparotomy was done through midline vertical incision (with differential diagnosis of ruptured uterus, abruption, non-obstetric causes of bleeding) with arrangements being made for blood and blood products. Laparotomy findings were as follows;
1. Hemoperitoneum 4 litre with clots.
2. Asymmetric enlargement of the uterus to 24 weeks more towards the right side, appearing blanched. Intact uterus ruling out rupture and abruption.
3. B/l tubes and ovaries normal, no congestion noted. An extra uterine source of bleeding excluded by a general surgeon.
4. Minimal oozing noted from the posterolateral aspect of the uterus which increased as the patients’ blood pressure increased after blood transfusion. On careful continued observation, a small ruptured vein was noted on the posterolateral surface of the uterus which started bleeding, the same ligated.
5. LSCS done to deliver the fetus (fresh still born), liquor was clear again excluding abruption. The uterus was septate with fetus in right half thus explaining the asymmetric enlargement of the uterus.
6. The uterus was closed in 2 layers followed by b/ l uterine artery ligation to control the diffuse oozing from the posterior aspect of the uterus. Multiple hemostatic sutures applied. She was transfused with 6 units of packed RBC’s, FFPS and platelets as the blood reports revealed severe anaemia with coagulopathy. The patient was admitted to the ICU for post op care. She was discharged on POD7 in stable condition.
Hemoperitoneum following spontaneous rupture of the uterine vessel is a very rare and life threatening complication. So far fewer than 150 cases have been reported. It is common among IVF pregnancy and with the history of endometriosis. Owing to recent advances in improved anaesthetic, resuscitative and operative technique the maternal mortality has been lowered from 50 to 3%. But perinatal mortality remains high. The diagnosis of this condition is rarely done before laparotomy. And at diagnosis, there is invariably massive hemoperitoneum.
In this conclusion, rapid diagnosis and aggressive fluid management together with prompt surgical intervention may be the only chance for a favourable outcome for both mother and child in such rare life threatening complication.
Specialist Obstetrician & Gynaecologist
*Image changed to retain patient’s confidentiality.